Psychosurgery spreads

Whatever the truth behind the initial inspiration of the lobotomy, the fact that it rapidly became such a widespread treatment for schizophrenia and other mental disorders is remarkable. James Watts was originally a student of John Fulton and by the end of the 1930s Fulton was a prominent figure in American psychiatry. Watts engaged in regular correspondence with Fulton, who met up with Watts and interviewed some of the early lobotomy patients. Convinced of the potential value of the procedure, Fulton spread the word among his network of influential colleagues and once Fulton was a public proponent of lobotomy, sceptics such as the Harvard psychiatrist Harry Solomon were won over. In particular, it is argued that Fulton’s support gave the procedure a neurophysiological legitimacy (Pressman, 1998).

It is interesting to acknowledge that a relatively small number of psychiatrists and neurosurgeons were responsible for spreading lobotomy across the globe. International travel in the 1930s and 1940s is insufficient to explain the widespread uptake. Moniz was a political man who was unlikely to have missed an opportunity for self-publicity. Walter Freeman, driven by his desire to achieve as much as his grandfather W. W. Keen, demonstrated his talent for ‘drawing a crowd’ at most of the conferences he attended. Together, they managed to put lobotomy in most of the mental hospitals in the USA in the 1940s. In 1939 Freeman went to a conference in Copenhagen, and although many Scandinavian psychiatrists were shocked, within 2 years the first lobotomy was being performed in Norway with Ørnulv Ødegård, the director of Gaustad Hospital in Oslo, at the helm.

The fact that Ødegård led with such enthusiasm resulted in a board of inquiry being set up by the Ministry of Health in Norway in 1992 to investigate claims of falsifications over the lobotomy cases. In 1996, the Norwegian Health Department agreed to pay compensation (approx. £10,000) to patients who had undergone lobotomy in Norway (Goldbeck-Wood, 1996). In an attempt to explain the use of lobotomy in Norway, the report (Utredning om lobotomy, 1992: 11) stated that:

The attitude of trendsetting individuals may be decisive for a development, especially in a non-homogenous society like the Norwegian one. The attitude of chief psychiatrist Ørnulv Ødegård can offer an explanation of why the use of lobotomy reached such an extent in Norway. (Cited in: Tranøy & Blomberg, 2005)

Norway was not alone, however. Within five years of Moniz’s first reports of prefrontal leucotomy, the procedure was being performed, outside the USA, in: Brazil (by Pimenta); in France (by Ferdière); in Italy (by Ventura, Ody, Rizzatti, and Sai); in Romania (by Bagdasar and Constantinesco); and the UK (by Hutton and McGregor, amongst others) (Hutton, Fleming & Fox, 1941).

Psychosurgery in a socio-economic context

The neurosurgical techniques employed by Freeman, Watts, and others were, unsurprisingly, crude and inconsistent. The use of external skull landmarks was unreliable and resulted in wide variation in the plane of section from case to case. Whilst the surgeon thought he was cutting brain tissue, often he was merely moving the brain laterally with the leucotome (Swayze, 1995). Despite the surgical problems (which were probably recognised at the time but not widely reported) the lack of effective treatments for chronically hospitalised and psychotic patients meant that the potential benefit of the surgery for selected patients was more compelling than the apparent risks of the procedure. Menninger (1948) illustrates some of the challenges in the public healthcare system with some statistics:

In the USA in 1946, 46% of all hospital beds were filled with psychiatric patients.

In 1943, there was an annual net increase of 33,000 in the hospital population, with 100,000 new admissions to state hospitals.

In 1946, the number of admissions had increased to 271,209. If the minimum standards set down by the American Psychiatric Association were to be met then the cost of inpatient treatment would be $500-700 million. The actual amount spent in 1945 was $165,743,122.

Already by 1946 state hospitals were overcrowded by 17.5%. Surveys at the time revealed that the ratio of patients to doctors in the mid-1940s was at least 250:1 in one-third of the state hospitals (Pressman, 1998, p.151). The survival of a state mental hospital was dependent on three factors: the number of admissions; the rate of discharge; and the number of beds available. Funding for new beds was seldom available; admissions were continuously rising; and so the only factor that the hospital could control was the rate of patient discharge. Treatments were limited and the potential crisis in hospital care undoubtedly led many to seriously consider any treatment which may help to help patients out of hospital.

Further, long-term patients in many public psychiatric hospitals in the first quarter of the 20th Century had an alarmingly high mortality rate, often from tuberculosis. Between the years of 1950 and 1964, more people died in United States ‘mental institutions’ than died in the Revolutionary War, the War of 1812, the Mexican War, the Civil War, the Spanish-American War, World War I, World War II, the Korean War, Vietnam, and the Persian Gulf War combined. In the twenty-five years between 1965 and 1990 the total number of inpatient deaths is estimated at over one million individuals (O'Meara, 2001).

Meanwhile, in the UK, the chances of discharge from mental hospital in 1949 was dependent on duration spent in hospital, and ranged from 7% (2-3 years in hospital) to 0.5% (25-30 years in hospital) (Robin, 1958). The early reports of positive and often dramatic outcomes in patients for whom no treatment was previously available resulted in an optimism that is easy now to criticise. Many proponents of psychosurgery were probably blinded to adverse effects and poor outcomes, despite it being known that frontal lobe damage or removal could cause changes in behaviour (Ackerly, 1935). The poorer outcomes reported in schizophrenia within five years of the first leucotomy (Freeman & Watts, 1945) did not deter psychiatrists and surgeons sufficiently to abandon the procedure for this group. Edward Strecker’s 1942 paper reported that out of five patients with chronic schizophrenia who underwent lobotomy, two were able to be discharged and three were improved (Strecker, Palmer & Grant, 1942). This paper, which was likely to have been widely-read at the time, is cited as having revitalised the role of lobotomy in chronic psychosis (Tierney, 2000).

Psychiatry in a social context

Prior to the 1920s, psychiatry as a medical specialty did not exist. Instead, patients with mental health problems would be treated by primary care physicians, neurologists, and physicians who were working in large public health asylums. Treatments were largely ad hoc, often improvised, and not influenced by any particular model or theory which underpinned the specialty.

In the early 1920s, psychiatry in the USA began to coalesce under a single banner, primarily because of the influence of one man, Adolf Meyer (1866-1950). Indeed, he reclaimed the term ‘psychiatry’ (which had become synonymous with asylum-based medicine) and sold this new specialty to a new generation of doctors. It can be argued that Meyer’s reforms would not have had such wide-reaching effects if it had not been for the First World War.

Struggling to deal with ‘war neurosis’ on an enormous scale, the USA needed new models of delivering psychiatric care to large numbers of people. The successes of the physicians on the front lines, in treating the mental health problems that arose out of the stresses of combat, convinced many that things could be done for sufferers of mental disorder and also illustrated the fact that mental ill health could arise in anyone if there was sufficient stress. The Great War also served to unite the private neurologist and public health asylum worker in the need to both screen out those unfit for military service because of vulnerabilities to neurosis, and also to return those suffering from the psychiatric consequences of combat to useful roles in society. Some may argue that the image of the psychiatrist as an agent of authority and social control was born out of this period. In 1926 William Healy, the chair of an American Psychiatric Association panel on the role of psychiatry in society, announced that:

“…it is exactly the psychiatrist’s proper business to take over the problems of mental adjustments that are so immediately and overwhelmingly involved in the problems of personality, of family and other social maladjustments, of misconduct, of vocational dissatisfactions, of educational misfittings in primary or secondary school or college.” (Cited in Pressman, 1998, pp 28-29)

1. Joe A. was a 39-year-old stockbroker who underwent bilateral frontal lobe resection to treat a large glioma. After the procedure, despite having no motor or sensory deficits, his personality and social judgement was clearly impaired, and was unable to plan for the future. Despite being able pre-operatively, post-operatively he was unable to work, having to rely on his family for care.

2. It was William Arnold who first suggested that Frances Farmer underwent a lobotomy in his 1978 book 'Shadowland', which was a fictionalised biography of Farmer. The 1982 film 'Frances' helped to perpetuate the claim. Interestingly, the film-makers created a fictional character 'Harry York' in order to claim that the film was based on original material, and not William Arnold's book.